Rule of the Month: Automatic Medicare Therapy Cap Tracking
Welcome back to the Rule of the Month! This month, we see how athenahealth’s “behind-the-scenes calculator” saves clients from tracking complicated Medicare expenditures by hand.
Here is the reality: Medicare implemented yearly financial limitations on covered therapy services (therapy caps) on January 1, 2006. These therapy caps applied to Physical and Occupational Therapy. A specific yearly dollar maximum amount limited the number of services rendered.
To make it even more complicated, the Deficit Reduction Act allowed exceptions to this dollar limitation in 2006. These exceptions were extended into 2007 by the Tax Relief and Health Care Act of 2006.
If the provider feels that additional services (over and above the limitation of the therapy cap) are medically necessary, the provider can request approval from the Medicare carrier or meet the guidelines for the automatic exemption and clearly document this in the medical record.
When the therapy cap exception has been approved or the guidelines for an automatic exception are met, a modifier can be added to the service to indicate this. If no modifier is added, the services could be denied.
Imagine the accounting nightmare for our clients!
- How does the office keep track of the amount billed over an entire year?
- How would the service that needed the modifier be identified?
- What if the limitation amount changed...?
Once again...athenahealth’s rules engine comes to the rescue!
Like a little calculator behind the scenes, athenahealth’s rules add up the amount charged and allowed amount, then warn our clients when the services are nearing the yearly maximum. The rules allow our clients to review the medical necessity of additional services before it is too late, request approval from Medicare if necessary, or review the guidelines for an exemption for documentation purposes.
The result: Increased profitability and more staff time to focus on patient care, not documenting complicated Medicare expenditures and exceptions!